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.� <br /> STATE ID NUMBER 00000023953003 <br /> APPLICATION FOR PERMIT TO OPERATE UNDERGROUND STORAGE TANK <br /> 0601 NEN PERMIT f 1 05 RENEWED PERMIT ( ) 07 TANK CLOSED <br /> ( ) 09 DELETE FROM FILE (NO FEE) <br /> 02 CONDITIONAL PERMIT ( 1 06 AMENDED PERMIT ( ) 08 MINOR CHANGE (NO SURCHARGE) <br /> I OWNER <br /> PUBLIC AGENCY ONLY <br /> FNAMI(CORPOPATION,INDIVIDUAL OR PUBLIC AGENCY) ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> COMPANY U.S.A. <br /> CITY STATE ZIP ADDRESS HOUSTONTX 77210 <br /> NORTH CHASE BLVD. <br /> II FACILITY <br /> DEALER/FOREMAN/SUPERVISOR <br /> FACILITY NAME RANDY VETESY <br /> EXXON SERVICE STATION <br /> STREET ADDRESS NEAREST CROSS STREET <br /> 3128 W. BENJAMIN HOLT <br /> ?STOCKTON <br /> UNTY ZIP <br /> CITY STOCKTON AN JOAQUIN 95207 <br /> MAILING ADDRESS STATE ZIP <br /> 3128 W. BENJAMIN HOLT TX 95207 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-478-6401 (X) 01 GASOLINE STATION ( ) 02 OTHER <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY : TOWNSHIP RANGE SECTION <br /> 4 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> DAYS: NAME(LAST NAME FIRST) AND PHONE W/AP.EA CODE NIGHTS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE <br /> HOFFMAN, S.D. 415-937-2991 HOFFMAN, S.O. 415-372-3361 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( ) 04 OTHER: lCONTAINER NUMBER 3 <br /> B. MANUFACTURER (IF APPROPRIATE): UNKNOWN YEAR MFG: 1971 C. YEAR INSTALLED 1971 ( ) UNKNOWN <br /> D. CONTAINER CAPACITY: 10000 GALLONS ( ) UNKNOWNjE::DOES THE CONTAINER STORE= ( ) O1 WASTE (X1 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES f 102 NO IF YES CHECK APPROPRIATE BOX(ES): <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( ) 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL l ) 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: ( ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( l 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) (X) 02 NON-VAULTED ( ) 03 UNKNOWN <br /> C. ( 101 DOUBLE WALLED (X) 02 SINGLE WALLED ( 1 03 LINED <br /> 0. (X) 01 CARBON STEEL f l 02 STAINLESS STEEL l ) 03 FIBERGLASS ( ) 04 POLYVINYL CHLORIDE ( ) 05 CONCRETE <br /> f ) 06 ALUMINUM l 1 07 STEEL CLAD [ ) 08 BRONZE ( ) 09 COMPOSITE ( 1 10 NON-METALLIC <br /> ( ) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> *A/ 1401 <br />